Mon March 25, 2013

Amid Syria's Crisis, Mental Health Care For Refugees

This is TALK OF THE NATION. I'm Neal Conan in Washington. More than 1 million people have fled to safety across Syria's borders. Many live in camps in Jordan, Lebanon and Turkey, which too often struggle to meet basic needs such as shelter, food and clean water. Some arrive wounded, and need medical care. Many suffer from the invisible wounds of trauma - everything from shelling or crossfire to the loss of a loved one, even torture. All of them have lost their homes.

If you've worked with refugees in camps like these, what questions do they ask you? Tell us your story - 800-989-8255; email us, talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION. Later in the program, the little-known friendship between first lady Mary Todd Lincoln and her emancipated dressmaker, Elizabeth Keckley. That's in a new play "Mary T. and Lizzy K." We'll talk the - that with the play's writer and director.

But first, Dr. James Gordon joins us from member station WSHU in Fairfield, Connecticut. He's founder and director of The Center for Mind-Body Medicine and wrote about his most recent visit to help Syrian refugees for the Atlantic. Thanks very much for being with us today.

JAMES GORDON: It's good to be with you, Neal.

CONAN: Set that scene for us. What did you see when you arrived at that refugee camp in Jordan, and what questions did people have for you?

GORDON: Well, some of the questions are quite unanswerable. The questions were things like: When am I going to get a couple more blankets? And one of them, it was very poignant, was: why don't the American people love us? We love them. And of course again and again, when is help going to come for Syria, when is the international community going to do something about what's happening to our country and to all of us.

CONAN: And as you say, these are unanswerable by somebody at your pay grade.

GORDON: Right, and then there are, of course, a number of answerable or hopefully answerable questions, which is: Can you help me to sleep? What do I do with the memories that come to me of night of being tortured? Or how can I help my child, who's wetting his bed or her bed every night? Those kinds of questions at least we can begin to help people find the answers for.

CONAN: And you travel with a team, so you're better prepared to deal with those things.

GORDON: Yes, and this is really a, kind of, exploratory trip. We're hoping to create a comprehensive program for the Syrian refugees in Jordan. And this was an opportunity to begin to - it was my second trip to the refugee camps and to Jordan to meet with refugees who are staying with families. And it's a way of exploring what's going on, of seeing how the program that we have to offer of self-care and mutual help, whether it makes sense or not to the refugees and to those who care for them.

CONAN: How do you get them to be forthcoming? So often, people are close-mouthed, particularly with foreigners.

GORDON: Well, you know, it's amazing. If you are really prepared to listen without judging, without pretending that you can fix something you can't fix, people want to tell their stories. And as they tell their stories, there are openings there where they are really saying OK, this is what's going on for me. Is there any hope for me? Is there anybody who can help?

And it's at that point, a combination of desperation and openness and some human connection between us, that I'm able to begin to teach them techniques and to see if they'd be interested in working more extensively with us.

CONAN: Your piece is called "Laughing with Syrians." Can you share that technique with us?

GORDON: Well, that I'm laughing now as you're telling it. It was - it really came to me. We use many, many techniques, with deep breathing for relaxation, and we use drawings and using mental imagery where people create a safe place for themselves. But as I was talking to this particular young man who had been a student in college, he'd been in the hospitality industry, and all of us as we were listening recognized the irony of that phrase, hospitality industry.

And in connecting with him, he said that, you know, I don't feel I can talk to anybody. I stay in my tent all day and all night with people. This is the first time I've been out in some time. And I said, well, what's going on? What's happening to you in the tent?

And he said, well, the images of being tortured - and he was strung up and badly beaten, and electrical wires were applied, and he was tortured on his genitals and all over his body - he said those images keep coming. And I said all the time? He said yes, they're there with me all the time.

And he told me that - I said, well, what do you like? What either used to give you pleasure or still does? He said, well, I used to like to cook. And it just came into my mind, as it sometimes does with any, I think any doctor or therapist when you're working with another human being, there's a moment when your intuition hopefully comes in. And I said, well, cooks, cooks like to experiment, don't they?

And he said yes, yes we do. And he brightened a little bit. And I said, well, would you do an experiment with me? And so we were kind of on the same team. And he said, oh, OK. And I said, well, I'm going to do some laughing with you. And he said, you know, I have nothing to laugh about. And I said, well, would you consider forcing it for a minute or to, and let's see what happens?

And he said OK. And at this point, about a dozen or 15 other people had gathered around us because they had - I think they had the feeling, because this was all being translated, that there was something that might be hopeful and helpful. So I just showed him how to laugh. It looks kind of funny because I'm forcing the laughter.

I don't want to blow your listeners away, but it was...

(LAUGHTER)

GORDON: Sort of, forcing it with the belly. And of course it looks a little strange, and they're looking at me as if I'm a little crazy. And so I assured them that I was a little crazy, but really willing to try the experiment. And they were. And I said, you know, what this may do is help to break you loose. You were tortured for 10 months, and in a way, the torturers still have you because you're reliving that torture.

So let's see if at least for a moment you can free yourself. So he did it with me, and all these other men and women who were standing around are also laughing with me. And afterwards I could just see his body, which had been incredibly tense, begin to relax a little. And a, kind of, smile came onto his face and onto the faces of others. And he said, well, you know, at least for a moment it wasn't there.

And so I said, well, if at least for a moment it's not there, then it's possible, and this may be something that you can do other times, other places when these terrible memories overtake you. And he agreed that it was something that made sense.

Now I don't use laughter that often, at all, with people, but it just came to me in that moment, and it was appropriate for the moment and appropriate for the particular young man and apparently for a number of the people gathered around, because I think the understanding is so clear that we are - among them, that we're still in the grip.

Even though we've crossed the border, even though we're not in physical danger, we're still in the grip of what happened to us and what's continuing to happen. And anything that will give us a little bit of freedom from that we welcome.

CONAN: It's a great story, and we'd like to hear from those of you in the audience who have worked in refugee camps, not - like this one, and there are sadly too many across the world in too many places and too many times, 800-989-8255. Email us, talk@npr.org. What questions did people have for you? What answers could you provide?

And Dr. Gordon, I have to ask: Yes, a few moments of relief, and maybe they've absorbed the technique, and maybe they can help themselves from here on out, but this is a drop in the ocean.

GORDON: It is a drop in the ocean, and what's needed here and what we're hoping to implement if we can get the funding for it, is a program in which we train hundreds of people who are working as helpers in the camp and in the community in Jordan: doctors, nurses, community leaders, leaders of women's groups, people who want to learn a total approach to help themselves; an approach that includes a number of different techniques and that provides group support, and then teach them, after they've learned how to help themselves, teach them to work with the whole population.

This is how we began actually in Kosovo, working in the refugee camps in Macedonia with a relatively small number of people whom we began to train. And subsequently this method of self-awareness and self-care became central to the whole community mental health system in Kosovo, where it's available to all two million people.

People get it, and we say to them if you're going to help others, you've got to help yourself first. You've got to learn these techniques from the inside out, and then you can begin to share them with others. And what we will do is we'll teach you, we'll train you, we'll provide ongoing supervision. We have about 20 Arabic-speaking faculty as part of our international faculty of 120.

I'll bring those people there, I'll bring some people from America, bring some people perhaps from Kosovo who have been through the wars; and we'll train a critical mass of people who will then be able to work in many settings with children, adults, people of all ages and all through all kinds of problems.

CONAN: And we understand that any program like this has to start somewhere, but aren't you being overtaken by events? Aren't people flooding in faster than you could possibly train people?

GORDON: Well, it's true. The flood of refugees is enormous. But we're used to working on a large scale. In Gaza, for example, where we've been working for about eight years, we have a team of about 450, and we've worked with over 100,000 people. And now we're working with them at the rate of 50,000 a year. So it's a huge influx. I don't know that we're going to reach everybody, but we can certainly reach some of the people who are most troubled, who are most in need of this kind of help, which will, you know, quiet their nervous systems, give them a little bit of perspective on what's happened and what's happening to them.

And very importantly, give them tools and a sense of personal power and personal control in a situation in which everything feels so out of control. And also, and I think this comes really fairly early on, a sense of hope and possibility, that at least some kind of change is possible. And if one kind of change in the way they feel and the way they think and the way they relate to other people - maybe, maybe, other kinds of change are possible also.

CONAN: If you've worked or lived in a refugee camp after a manmade or natural disaster, give us a call, tell us how you saw people react and cope with trauma, 800-989-8255. Email us, talk@npr.org. Our guest is Dr. James Gordon, founder and director of The Center for Mind-Body Medicine. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

(SOUNDBITE OF MUSIC)

CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington. On Friday, on his visit to the Middle East, President Obama met with Jordan's King Abdullah II. He pledged an additional $200 million to help Syrian refugees flooding across that country's border. So far Jordan has taken in the largest number of Syrian refugees of any of that country's neighbors, close to half-a-million people.

If you've worked with refugees at camps like these or after a natural disaster, how do they deal with trauma? What works? Give us a call, 800-989-8255. Email us, talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.

Our guest is Dr. James Gordon, a psychiatrist who's worked with refugees dealing with mental trauma. And joining us now is Andrew Harper, head of the UN Refugee Agency in Jordan, who joins us via Skype in his home in Amman. Good of you to be with us.

ANDREW HARPER: It's great to be here, Neal.

CONAN: And what are you hearing from Syrian refugees? What are the priorities?

HARPER: Well, the priorities are to be safe, and that's the most important element. So we're seeing thousands of Syrians fleeing their homes every day. We're seeing hundreds and usually over 1,000 to 2,000 crossing the border into Jordan at night. As we speak, there's quite a lot of fighting along the border, which is only an hour away from here.

And when we're up at the border, because we have teams up at the border every night, they're basically taking women and children, the elderly, even people in wheelchairs and helping them get across the border. And this is done with the full support and cooperation with the Jordanian government, who have been absolutely fantastic in this critical situation. And yeah - sorry, go ahead.

CONAN: I was just going to say, so in that situation, you said safety is most important, but I assume that includes things like shelter and food and water and medical care.

HARPER: Yeah, well, the first thing is to get them out of harm's way. So what happens is we get the refugees, we move them away from the border; we do that with the Jordanian army and ILM. And we get them to a transit site, where we register them, and then we move them to Zaatari Camp at the moment, where we provide them with accommodation, food, water, health care, basically everything that someone would need in this environment.

Again it's a refugee camp, so nothing is perfect, but at least we get - we keep people alive. We get them out of harm's way. And as you said originally, there is some 500,000 Syrians, or getting close to 500,000 Syrians, in Jordan. As far as the Zaatari refugee camp, we've actually had about 260,000 Syrians come through.

And if you just sort of break that down into demographics, we've probably had about 60,000 children between zero and four come through that. And it just gives you an idea of some of the challenges that we have when you have children who have basically been born on the other side of the border, when you have people who are over 100 years old who have fled their homes.

You realize that it's not something that they've chosen to because there was any other option. They've been forced out of their homes. There's artillery firing, at the moment. We know that people are being killed very close to the border, at the moment. We've been at the border when people have been fired upon from the other side. So you throw all this into the mix, and you obviously have a lot of trauma and issues with mental health, with a lot of people.

One of the biggest challenges that we have is actually going into the urban environment, where most of the refugees are, and trying to find those people who are most in need because the people most in need are the most unlikely to come forward to seek help. And that includes the women, elderly and children. So we need a lot more resources; we need a lot more help in dealing with the population, which has suffered so much - just to the north of us.

CONAN: Dr. Gordon, I don't know if you had the chance to meet with Andrew Harper, or his equivalents, while you were there. But I wonder, given the scale of the problem he's describing and obviously, if anything, the flow of refugees is increasing - not going the other way - have you been able to - have any questions for him about what services you might be able to provide?

GORDON: Well, yes, and I would very much like to meet with you, Mr. Harper, when we're next back there. I think what I've seen is that many of the health services and many of the social services, they're being provided. There are a number of different facilities throughout the camp. And I think from my point of view, what I would like to be part of is an effort - and what all of them seem to want us to be part of, including the people from UNHCR - is an effort to make available this kind of psychological support along with the medical care, as part of systems of distribution of food; as part of attention to shelter.

And I agree with you completely, that the issue is how to reach the people who are least likely to come forward. Those are often the most traumatized people. And so I think the way to do it is through the provision of the services that they are already coming forward to look for - medical services but also food, and social services of other kinds. And so I would love to work with you, to figure out a way to do this that makes the kind of service we have available very much a part of what you're doing.

CONAN: Andrew Harper?

HARPER: Well, what we've got is, we've got a lot of very dedicated agencies already on the ground. And I know - for instance, IMC, which is a very good U.S. NGO, is doing a lot of mental health. We've got a mental health working group that's assisting coordinating efforts and activities in that sector. So I dare say, what would be best is if you actually hook in with the existing structures to see where the gaps are.

Again, what - one of the main challenges that we've got is just the numbers of people who are coming over. There's no shortage of needs that need to be addressed because we've probably got about 500,000 Syrians here, at the moment, and the rate the people are coming across, we could easily have another 500,000 by the end of the year. So almost all sectors require significant amounts of support.

The announcement by President Obama of $200 million to the government of Jordan is certainly welcomed. That will be going to the government, U.N. agencies, NGOs who are also working on the front line, who have received a lot of support from the U.S. government to date; and we're extremely thankful for that. However the needs just keep growing. And given the situation in Syria, we appear to be one of the few options that people have who are fleeing the conflict.

They are coming from as far afield as northern Syria, all the way down to the southern border and crossing into Jordan. So any support that we can receive from any of the organizations that are in the U.S. who come into our coordination system, we're extremely encouraging and would be welcoming.

GORDON: One thing that I think is really important is to support those people who are already there and working in the organizations. And that's what we try to do. We try to work through all of the organizations that are doing the work because the caregivers themselves, as you've sort of implied by the numbers that we're talking about, are often quite overwhelmed.

And you see them, and they're - you know, they're almost stunned by the level, and the quantity, of the problems with which they're having to deal every day. So our attempt is to help them, initially help them deal with all the issues they have and they have to face; and then help them begin to integrate model - our model and others, into their work.

The other thing I think that's really important, that I've seen in other refugee situations in several different places, is that people want to be active. The refugees themselves want to be engaged in helping one another out. We met with a group of 20 leaders of the Syrian refugee community who happen not to be living in the camp. And their whole aim, what gives meaning to their lives and hope for them, is to be able to help others.

So I think another function of providing the kinds of services that we do is giving the Syrians themselves, as well as the members of the international community and the Jordanians, an active way to be of service to many people. And I think that could be very helpful in lifting morale. And I've seen that in other camps, where people are able to do, you know, a number of useful things for friends, family, and the people who are living around them.

CONAN: Andrew Harper, could I ask how close you are to being overwhelmed? It's half a million or thereabouts, so far. And again, we fear it could be another half million before the end of the year.

HARPER: Well, our job doesn't allow us to be overwhelmed. We have to ensure that we can do whatever is necessary to provide the most basic services, and we just have to adapt according to the flows. But there's only so much like, a country that - Jordan can continue to absorb. It's a relatively small country, given its population. The fact that it's already got several million Palestinian refugees; it's hosted hundreds of thousands Iraqi refugees; and now, it's got half a million Syrians. It's a desert. It's a desert country. It's the fourth water-poor country in the world. Its economy has been largely shattered by the situation to the north of it, which blocks its transport routes to Europe and Turkey.

So it's suffering. It's suffering across the board. It's having to share its meager resources with another half-million people. And those resources are already stretched because the education system is stretched, the health system is stretched, just providing utilities.

Zaatari camp consumes about 3 and a half million liters of water a day. UNICEF is providing 3 and a half million liters of water a day. If we set up another camp for another hundred-thousand people, then it's going to be 7 million liters of water a day. So very soon, we're reaching 10 million liters of water a day, in a country which cannot afford to give away so much water; electricity - across the board, Jordan is suffering. But again, the tremendous thing about Jordan is it's not complaining. It's just saying, we do need support, but the government is saying, we're not talking about closing borders to refugees. We will continue to maintain our fantastic tradition of generosity and hospitality to those people in need.

But there is an obligation. There is a responsibility of the international community to do more. And again, the U.S. government has stepped up to the plate, and that - I think everyone is very thankful for that. But what is the rest of the world doing in regards to supporting Jordan? Like, Jordan is a keystone country in the Middle East who's had to absorb - and do more than what anyone could possibly expect, in absorbing the humanitarian disaster that's taking place in Syria. But we will not fail in regard to providing protection to the refugees. But it could be made a lot easier if those resources being provided commensurate with the numbers of refugees that are coming across into this great country.

CONAN: Well, Andrew Harper, thank you very much for your time today. We appreciate it. We'll let you get back to work, or maybe even get some sleep.

HARPER: There's a lot of fighting up at the border, so we'll probably be going up to the border tonight.

CONAN: Well, thanks very - again, very much for your time, and good luck.

HARPER: Thank you.

CONAN: Andrew Harper is head of the U.N. Refugee Agency, with us on the line - Skype - from his computer there, at his home in Amman, Jordan. You're listening to TALK OF THE NATION from NPR News.

We have a couple of emails and a phone call I want to get to. This, from Jill(ph) in Louisiana: As a registered nurse in Southwest Louisiana, I worked with Katrina evacuees and used imagery in general terms - much like Dr. Gordon is asking, what do you like? Everyone I worked with - with a systolic blood pressure of over 200 was able to bring it down under 200, usually by 20 to 30 points, with this alone.

That, from Jill in Louisiana. Yes, important to remember the technique, and need to remember it's not just crisis - war refugees. It's not just in the Middle East. It's everywhere.

GORDON: Right. That's certainly true. And one of the things that she's pointing out is, first of all, the possibility of using simple techniques. We use mental imagery. We use deep breathing. What's also crucial is bringing people together in groups. First of all, you can't work with people simply individually. It's much more efficient to work with people in groups. Second, people can support each other and learn together.

And the next point is, this has to be ongoing because what presents as a psychological problem now can readily become a physical problem. If your stress is elevating your blood pressure and the stress continues, that elevated blood pressure may be leading you to a heart attack down the road.And we see this - I saw this in Bosnia after the war, with the incidence of chronic illness of every kind going off the charts because of the levels of stress, in four years of the siege in Sarajevo.

CONAN: Let's get a caller in. This is Ryan(ph), and Ryan's on the line with us from Houston.

RYAN: Hi. Thanks for taking my call.

CONAN: Sure. Go ahead.

RYAN: I, personally, was never at a refugee camp. But I had a friend, and he lives in London now, but he was at the refugee camp - I think it was Baqa'a, in Lebanon - which I checked online really quick. And the number of refugee camps, according to the most recent count, is upward of 90,000 people in just that camp.

And the general things that he was experiencing was this hopelessness, this idea of why isn't more help coming. Why isn't there a greater push for Assad to be - to step down? Just - it kind of started out as anger at Western interests for not, you know, doing more to get Assad to step down, or doing more to stop the civil war before it got way out of hand. But now, it's just kind of given way to this hopelessness of, why is this happening?

GORDON: Right. And I think that's really quite pervasive in Zaatari - and not just in Zaatari, but throughout Jordan - with the refugees who, as Andrew Harper said, are flooding Jordan. And I think that - that's an answer that's a political answer. It's one we, obviously, need to pay attention to. In the meantime, it's really important to see that people can take some kind of control over some aspects of how they feel and think, and how their bodies move, and what their daily life is like.

So it's a beginning, in a situation where the political situation is in the control of the larger world; where they can at least have a sense of control over themselves and - I think this is very important in refugee camps as well - a sense of active participation in doing things that are productive in the camp, and for those who are living among the general population.

CONAN: Ryan, thanks very much for the call.

RYAN: Thank you.

CONAN: And quickly - we just have a few seconds left - but don't children have special needs? Yes, they're more resilient, but there's also special terrors when you're a child.

GORDON: Children are both more - are more resilient, in many ways; but also, this kind of trauma has significant effects on their psychological, physiological functioning, and even on the structure of the brain. So it's crucially important to work with children. One of the ways we sometimes engage those hard-to-engage adults is by saying, well, you need to learn what we have to teach so you can help your children. And once that message starts getting out, we had so many mothers flooding the meetings that we were having for mothers and children. They were all bringing along their children.

And we were teaching the mothers techniques of self-care so they, in turn, could teach their children. It's absolutely crucial to work with the children. And even if the children sometimes look like they're smiling, you find out that that child who may be smiling now, is crying all night long. So yes, focus has to be on children.

CONAN: Dr. Gordon, thank you very much for your time today. We all wish you the best of luck.

GORDON: Thank you very much. Great to be here, Neal.

CONAN: James Gordon is founder and director of The Center for Mind-Body Medicine. He wrote about his most recent visit to help Syrian refugees, for The Atlantic. And he joined us today from member station WSHU in Fairfield, Connecticut.